What is dysplasia?

A

Dysplasia is the medical term for abnormal cells on the cervix caused by the HPV virus. If the abnormalities are mild and few in number, they usually go away without treatment. However, some cases of moderate dysplasia, and most cases of severe dysplasia, will not go away on their own. At this stage, the cells are considered "pre-cancer": In other words, if they are not found and treated, they could develop into cervical cancer.

Depending on the extent of abnormal cells present, dysplasia is categorized by healthcare professionals as:

Mild, or "CIN 1": CIN stands for cervical intraepithelial neoplasia. If the dysplasia is "level 1," that means only about one-third of the cervical cells are abnormal. In addition, the cells don't look as clearly abnormal as in moderate or severe dysplasia. It's estimated that one out of six women will develop CIN 1, which usually goes away on its own and does not require treatment. CIN 1 also may be called LSIL (low-grade squamous intraepithelial lesion).

Moderate, or "CIN 2": About two-thirds of the cervical cells are abnormal. Another term that may be used for CIN 2 (and CIN 3) is "HSIL" (high-grade squamous intraepithelial lesions).

Severe, or "CIN 3": Almost all of the cervical cells are abnormal, or pre-cancerous. These cells also look the most obviously abnormal, compared to CIN 1 or CIN 2. It's estimated that one in every 25 women will develop CIN 2 or 3.

Q

Who is most at risk of getting dysplasia?

A

Since high-risk types of HPV are the primary cause of dysplasia, anyone who has ever had intimate, skin-to-skin (genital) contact with a partner is at potential risk of developing the condition.

However, other factors may increase the likelihood that an HPV infection develops into pre-cancerous cells (and later, into cervical cancer):

Exposure while in the womb to a medication called diethylstilbestrol (DES), which was prescribed to many women to prevent miscarriage between 1938 and 1971.

A first-degree relative (mother or sister) with a history of cervical cancer, which the InternationalJournal of Cancer reports increases personal risk three-fold.

Health conditions that weaken the body's immune system, such as HIV/AIDS.

Smoking, which interferes with the body's ability to fight off infection. It's estimated that smoking doubles the risk of abnormal cells developing into CIN 3.

Low levels of folic acid (a type of Vitamin B).

Q

What are the symptoms of dysplasia?

A

Dysplasia does not have warning symptoms. If symptoms such as vaginal bleeding or low back pain occur, the condition may already have progressed to cervical cancer. That is why it is important to be screened regularly with a Pap and (if you’re age 30 or older) the HPV test. (These symptoms may be caused by other conditions, so don’t jump to conclusions! Consult with your doctor or nurse.)

Q

How is it diagnosed?

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Dysplasia usually does not have any symptoms. Thus, it is important to diagnose it through regular cervical cancer screening, including a regular Pap and (if you’re age 30 or older) the HPV test. If your Pap is clearly abnormal, or if testing shows you have an HPV infection that isn't going away (determined by repeating the HPV test a year later), your doctor or nurse practitioner should perform an exam called a colposcopy to look at your cervix more closely. During the colposcopy, a biopsy, in which a sample of cervical tissue is removed for analysis, is often taken to help confirm whether dysplasia is present and whether it requires treatment.

However, colposcopy is not foolproof. According to the American Society for Colposcopy and Cervical Pathology (ASCCP), several recent studies suggest that about one-third of less-extensive cases of CIN 2/3 are missed by colposcopy, with or without a biopsy. Thus, if the cervix appears normal during colposcopy, re-testing with an HPV test 12 months later (or with a Pap smear after six and 12 months) is recommended. If HPV continues to be present or the Pap remains abnormal, another colposcopy is a good idea.

Q

How is dysplasia treated?

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If you have CIN 1, it is common to simply monitor your condition through screening – usually a repeat HPV test after a year. (Another option is to repeat the Pap test at six and 12 months.) That's because the Centers for Disease Control and Prevention estimates that 60 percent of CIN 1 cases go away on their own, without treatment. (In contrast, that's true for only 40 percent of CIN 2 cases.) If re-testing shows the HPV infection is still there, or if the Pap result is abnormal, the colposcopy exam should be repeated.

If, however, you have CIN 2 or CIN 3, there are several methods your physician or other healthcare provider may use to eliminate the abnormal cervical cells. These treatments fall into one of two general categories: “ablation” (in which the abnormal cells are vaporized or otherwise destroyed while still in the body) and “excision” (in which the cells are cut out with a scalpel or laser). Excisional procedures also allow a portion of tissue to be sent to a lab for later analysis (also called a biopsy).

Special note for young or pregnant women:

Adolescents (age 13-20) and young women. The consensus guidelines published in the American Journal of Obstetrics & Gynecology state that in some cases, it is acceptable in this age group to delay treatment of CIN 2 for up to two years, while monitoring them carefully with colposcopy and Pap testing every six months. This is because girls of this age are at very low risk of developing cervical cancer.

Pregnant women. The consensus guidelines also state that unless invasive cancer is diagnosed, treatment and follow-up examinations should be delayed until at least six weeks after delivery.

Ablative treatments include:

Laser therapy:A tiny beam of high-intensity light is used to vaporize abnormal cells. The area and depth of treatment can be very precisely controlled.

Cryotherapy:A probe is placed against the cervix, cooling it to sub-zero temperatures and damaging abnormal cells by freezing them. The damaged cells are shed during the following month in a watery discharge. Note, however, that the effectiveness of cryotherapy is limited by the reach of the probe used to freeze the abnormal cells. In addition, it does not – like several of the other dysplasia treatments – produce a sample of tissue that can be analyzed to rule out the presence of cervical cancer. Thus, treatments other than cryotherapy are more suitable for larger areas of tissue identified as CIN 3, since they are most likely to contain invasive cancer.

Excisional treatments include:

LEEP (loop electrosurgical excision procedure):In probably the most widely performed dysplasia treatment, a fine wire loop, through which electrical energy flows, is used to remove abnormal tissue. It can be done as an outpatient, with local anesthesia.

"Cold-knife" or laser conization:A cone, or cylinder-shaped piece of the cervix, is removed with a laser or by cutting it out with a scalpel. This procedure is often done when more extensive tissue must be removed. Such procedures performed using a scalpel have a higher rate of complications than those done with a laser.

According to expert consensus guidelines published in the October 2007 issue of the American Journal of Obstetrics & Gynecology, all of these treatments are equally effective in eliminating dysplasia and reducing the future risk of invasive cancer. However, excisional treatments are recommended for women who are being treated for recurrent (repeat) dysplasia (CIN).

Q

Is the treatment always effective? Can the condition come back?

A

Treatment of dysplasia is effective for most women – but not for everyone. Consensus guidelines published in the American Journal of Obstetrics & Gynecology (AJOG) report that the failure rate for dysplasia treatment is generally 5-15 percent. As a result, the incidence of invasive cervical cancer among women previously treated for dysplasia is substantially greater than in the general U.S. female population. Follow-up exams are essential.

The American Society for Colposcopy and Cervical Pathology (ASCCP) recommends that HPV testing be repeated six to 12 months after treatment. If infection with a high-risk type of HPV is still present, says the ASCCP, a repeat colposcopy exam should be done. However, if testing shows the HPV infection is no longer active, you can return to your normal cervical cancer screening routine. Note that Pap testing also can be used for follow-up evaluation – one Pap six months after treatment and a second one six months after that. However, the AJOG guidelines state that “systematic reviews” have found that when used for post-treatment follow-up, the performance of HPV testing exceeds cytology (Pap testing).

Q

Will dysplasia interfere with your ability to have a child?

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Neither dysplasia nor its treatment will interfere with your ability to get pregnant. However, excisional treatments, such as LEEP and cold-knife conization, increase a woman's risk of experiencing pre-term labor, requiring a cesarean section and having a low-birth weight infant. (To date, most studies have not shown ablative treatments to be associated with these outcomes. However, a definitive conclusion cannot yet be made.) If you want to have children in the future, discuss these potential complications with your physician or other healthcare professional.